chapter one overview of emergency medicine

Chapter One Chapter One Overview of emergency Overview of emergency

medicinemedicine

Chapter One Chapter One Overview of emergency Overview of emergency

medicinemedicine

Jia XuThe First Affiliated Hospital of College of Medicine, Zhejian

g University

Emergency Medicine

第一章绪论：沈洪

What Is Emergency Medicine? What Is Emergency Medicine?

In the words of the International Federation for Emergency Medicine :

"Emergency medicine (EM) is a medical specialty—a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders. It further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development."


What does an emergency What does an emergency physician (EP) do?physician (EP) do?

assessment

disposition

acute and urgent illness and injury

(24/7)

acute and urgent illness and injury

(24/7)

the core of the core of emergency medicineemergency medicine

diagnosis

triage

management


The needs of societyThe needs of society

Numbers of emergency department visits in U.S.

strategies

Old persons always have diseases refers to many organs.

Urgent patients

dieaseslongevity

The rates of cardio-cerebral-vascular disease are higher.

“Golden Time”

With the development of medical science, timely EM is proved more effctive. EM servies are easier to access.

1996:

87 million ；34.2 per 100

2006:

119 million ；40.5 per 100

36%

Emergency medical Emergency medical

services systemservices system

（（ EMSSEMSS ））

Emergency medical Emergency medical

services systemservices system

（（ EMSSEMSS ））

Emergency Medicine

Chapter One Overview of emergency medicineChapter One Overview of emergency medicine


The constitution of The constitution of EMSS EMSS

prehospital emergency

hospital emergency

critical care

EMSSEMSS


(1) Personnel (1) Personnel

In most urban areas :

1 ） public safety

2 ） ambulance personnel

in rural or wilderness areas ：1 ） citizen volunteers

2 ） park rangers

3 ） ski patrols, et al.

The 15 elements of EMSSThe 15 elements of EMSS


(2) Training(2) Training

First Responder (FR)

EMT paramedic (EMT-P)

EMT intermediate (EMT-I)

EM Technician basic (EMT-B) CPR, spinal immobilization, bleeding control, basic emergency care procedures

Non-ambulance crew

Ambulance crew

Ambulance crew

Ambulance crew

use of AED; safe transportation; assist patients using their own medicine

patient assessment; give additional medications

basic ECG interpretation, the ability to give some cardiac medications


(3) Communications(3) Communications

the universal emergency telephone number

120120ChinaChina


(4) Transportation(4) Transportation

Ground ambulances :Ground ambulances :

Basic life support (BLS) Basic life support (BLS)

ambulances EMS-B;ambulances EMS-B;

Advanced life support (ALS) Advanced life support (ALS)

ambulances EMS-P.ambulances EMS-P.

Air Air ambulancesambulances


(5) Facilities(5) Facilities

Rules:Rules:the closest

appropriate hospital the patient's choicea specific hospital

with better resources to treat seriously ill or injured patients (e.g., trauma center, cardiac center)


(6) Critical Care Units(6) Critical Care Units

traumaburnsspinal cord

injuryneurosurgical respiratory

failure cardiac care

Emergency intensive care units (EICU)


(7) Public Safety Agencies(7) Public Safety Agencies

police carfire engineambulance

1) the FR of EMSS

2) are needed to

provide medical

care in hazardous

circumstances


(8) Consumer Participation(8) Consumer Participation

public support: political, financial

public first aid training

the implementation of a universal telephone

number system.


(9) Access to Care(9) Access to Care

An important principle of EMS is that all

individuals deserve timely access to the

system when necessary.


(10) Transfer of Care(10) Transfer of Care

ReceiverReceiverSenderSender

inform relevant inform relevant informationinformation

response and prepareresponse and prepare


(11) Standardization of Patients' (11) Standardization of Patients' RecordsRecords

use a similar reporting form by medical records and prehospital records

interpreted quickly and easily by receiving nurses and physicians


(12) Public Information and (12) Public Information and EducationEducation

Each year, India's monsoon rainy season causes massive devastation, resulting in the loss of homes, cattle, commerce and — above all — human life.

Photo from 《 Equipping Villages for Disaster 》

The villagers demonstrate proper use of lifesaving

flotation devices.


(13) Independent Review and (13) Independent Review and EvaluationEvaluation

Governing agencies should be assured that there is ongoing review of the EMS system.

NeedsNeeds • monitoring of radio communicationsmonitoring of radio communications

TimesTimes• review of response timesreview of response times • review of transfer timesreview of transfer times

• review of patient care recordsreview of patient care records • review of positive result ratereview of positive result rateEffectsEffects


(14) Disaster Linkage(14) Disaster Linkage

Public safety agencies should keep the EMS system informed of potential disaster situations.

Hospitals should keep the EMS system informed of their capacity to receive certain kinds of patients under disaster conditions.

Photos from 2008 5.12 China Wenchuan earthquakes.


(15) Mutual Aid Agreements(15) Mutual Aid Agreements

EMSS should develop mutual aid

agreements with neighboring jurisdictions

so that uninterrupted emergency care is

available when local agencies are

overwhelmed or unable to provide services.


The 15 elements of EMSSThe 15 elements of EMSS

The basic elements of patients care

Thus, an EMS system is the entire system to provide care to emergency patients from the initial call to definitive care.

The development of The development of emergency medicineemergency medicineThe development of The development of emergency medicineemergency medicine

Emergency Medicine



(1) History(1) History In 1792, a clever French army surgeon devised the

“flying ambulance” during the French Revolution

Dominique Jean Larrey,(1766-1842)

“the father of emergency medicine”

French Revolution

The “flying ambulance”


Emergency medicine (EM) as a medical specialty: Prior to the 1960s and 70s: Emergency department

were generally staffed by physicians on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists.

The “Alexandria Plan”: the first groups headed by Dr. James DeWitt Mills along with four associate physicians was established to provide 24/7 year round emergency care at Alexandria Hospital, VA, U.S.A..

(1) History(1) History


In 1970: the first emergency medicine training program at Cincinnati General Hospital was established.

During the 1970s: the establishment of American College of Emergency Physicians (ACEP) ;

the recognition of emergency medicine training programs by the American Medical Association (AMA)

In 1979: a historical vote by the American Board of Medical Specialties made EM become a recognized medical specialty in America.

(1) History(1) History


Anglo-American model: “brings the patient to the hospital”. Australia, China, Japan, the United Kingdom and the United States, etc.

Franco-German model: “brings the hospital to the patient”.

Austria, France, Germany, Russia, Sweden, and Switzerland, etc.

(2) The Development of Emergency (2) The Development of Emergency Medicine WorldwideMedicine Worldwide

Emergency medicine development models


Reasons for the influence of the Reasons for the influence of the Anglo-American modelAnglo-American model

The predominance of American academic emergency medicine: which provides the research, journals, textbooks, and practice guidelines used throughout the world (eg. American Heart Association,

Advanced Cardiac Life

Support, Advanced

Trauma Life Support)

24/7 year round service concept

15 years popular TV shows “ER”


(3) Stages(3) Stages in the development of in the development of emergency care systemsemergency care systems

Features Underdeveloped Developing Mature

Specialty systems

National organization No Yes Yes

Residency training No Yes Yes

Board certification No Yes Yes

Official specialty status No Yes Yes

Academic emergency medicine

Specialty journal No Yes Yes

Research No Yes Yes

Databases No No Yes

Subspecialty training No No Yes

Patient-care systems

Emergency physicians House staff, other physicians Emergency medicine residency–trained Emergency medicine residency–trained

ED director Other physician Emergency physician Emergency physician

Prehospital care Private car, taxi BLS/EMT ambulance Paramedic/physician ambulance

Transfer system No No Yes

Trauma system No No Yes

Management systems

Quality assurance No No Yes

Peer review No No Yes

Such as Armenia, China, Israel, the Philippines, Saudi Arabia, South Korea, and Turkey.

Include Australia, Canada, the United Kingdom, and the United States

Unique Aspects of Unique Aspects of Emergency Emergency

Medicine PracticeMedicine Practice

Unique Aspects of Unique Aspects of Emergency Emergency

Medicine PracticeMedicine Practice

Emergency Medicine



(1) Time and Volume Pressure(1) Time and Volume Pressure

EPs must prepared to “treat first and ask questions later.” Because in a true emergency, seconds or minutes may make the difference between life and death or serious disability.

The time available for one given patient is severely limited by the demands of other patients being managed concurrently. (10-15 mins per patient)


(2) Variety of Conditions(2) Variety of Conditions

must master comprehensive knowledge must manage a wider variety of conditions must shift cognitive frames rapidly


(3) Paucity of Information(3) Paucity of Information

unaware of patients’ history

old records are often unavailable

history be provided from bystanders

or EMS providers


(4) Limited Therapeutic Options(4) Limited Therapeutic Options

treatment strategies always based on limited

laboratory and imaging tests.

the tolerance for therapeutic failures or

misadventures is more limited than in

nonemergencies.

EPs often can provide only temporizing or

symptomatic treatment, while definitive

management must be deferred to another

specialist.


(5) Constraint of Disposition(5) Constraint of Disposition

No matter how uncertain the diagnosis or how much extended observation or testing might help, every patient encounter in the ED ultimately reduces to three binary decisions:

(1) Is the patient sick or not sick?(2) If the patient is sick, should I treat this

problem or not treat?(3) Should I admit or discharge the patient?


(6) Work in an environment (6) Work in an environment in which patients diein which patients die

Why the person died?Will the patient die?Will the illness have an impact on survivors?Does the illness put health-care workers and

society at risk?Should an autopsy be performed for medical

or legal reasons?Does the family desire organ donation? Needs to be on guard for the occasional viol

ent reaction by survivors.

General General PPrinciplesrinciples of Emergency Mediciof Emergency Medici

ne Practicene Practice

General General PPrinciplesrinciples of Emergency Mediciof Emergency Medici

ne Practicene Practice

Emergency Medicine



The Principles of EMThe Principles of EM

The principles of emergency medicine are

provide effective care to patients who have

entrusted EPs with their care.

The questions below can be used as a simple guide for EPs.


(1) Is the Patient About to Die?(1) Is the Patient About to Die?

( Critical patient )

( Emergent patient )

( Nonurgent patient )

illness or injury that may illness or injury that may progress in severity if progress in severity if treatment is not begun quicklytreatment is not begun quickly

have a low probability have a low probability of progression to a of progression to a more serious conditionmore serious condition

a life-threatening illness or injury a life-threatening illness or injury with a high probability of death if with a high probability of death if immediate intervention is not begunimmediate intervention is not begun

Look for symptoms of a life-threatening emergency, not a specific disease.

Anticipate impending life-threatening emergencies in the apparently stable patient.


(2) What Steps Must Be Undertaken (2) What Steps Must Be Undertaken to Stabilize the Patient?to Stabilize the Patient?

Breathing Circulation

Airway Neurologic deficits

Do not delay necessary

primary interventions while

awaiting completion of

ancillary testing. What do we need to treat first for a hemoptysis patient with apnea?


(3) What Are the Most Potential (3) What Are the Most Potential Serious Causes of the Patient? Serious Causes of the Patient?

Develop a list of "What will kill my patient the fastest?"

the vital signs

history

physical examination

ancillary assessments

Suspiciouscauses

What is the life threatening symptom for a bowel obstruction with septic shock?


(4) Could There Be Multiple Causes (4) Could There Be Multiple Causes of the Patient's Presentation? of the Patient's Presentation?

"Is this all there is?"

Examples 1:

new-onset seizure and hypoglycemia in an older diabetic patient.

intentional or accidental medication overdose?

perhaps worsening renal insufficiency?


Example 2:

Near-syncope and abdominal pain in an apparently intoxicated college coed

a ruptured ectopic pregnancy? or perhaps a ruptured spleen secondary to undisclo

sed physical abuse by her BF? or...?

(4) Could There Be Multiple Causes (4) Could There Be Multiple Causes of the Patient's Presentation? of the Patient's Presentation?

Frequent reassessment the Frequent reassessment the multiple possibilities responsible for multiple possibilities responsible for

patient's condition is imperative. patient's condition is imperative.

Frequent reassessment the Frequent reassessment the multiple possibilities responsible for multiple possibilities responsible for

patient's condition is imperative. patient's condition is imperative.


(5) Does This Patient Need to (5) Does This Patient Need to Be Admitted to the Hospital?Be Admitted to the Hospital?

Whether an emergency condition exists.

Does the patient have timely, accessible

follow-up?

Are unresolved abuse or self-care issues

involved?

Are you, as the EP, comfortable

discharging the patient?


(6) How to Treat the D(6) How to Treat the Dischargedischarged P Patient?atient?

Recommend appropriate follow-up and

provide written discharge instructions.

Instruct the patient when to return for

further evaluation. Provide the patient with information

regarding treatment and diagnosis.


(6) How to Treat the D(6) How to Treat the Dischargedischarged P Patient?atient?

Example: Glacial acetic acid accidental overdose

patient:

burning pharyngeal mucosa esophageal stenosis in six months

Thanks!Thanks!Thanks!Thanks!

Emergency Medicine

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